Do I have to do this every time?: Implementing a PTSD ... · stakeholder engagement and a workflow...
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Demographics Figure 1. Screening Tool Results Methods • Study Type: Mixed-methods pilot study to examine feasibility and acceptability of screening tool implementation. • Participants: Patients, behavioral health and primary care providers, medical assistants, health and wellness coaches, a registered nurse and intensive case manager at TRUST from October 1, 2017 to March 31, 2017. • Study Procedure: We worked with staff to create stakeholder engagement and a workflow for administration of the PCL-C (PTSD CheckList- Civilian Version) and PHQ-9 (Patient Health Questionnaire) to meet the requirement of screening at every visit. • A receptionist gave the screening tools to patients at registration for their appointments. Patients completed the survey tools in the waiting room and gave results to clinic staff. Survey results were entered into the EMR. • We assessed implementation of the screening tools through multiple PDSA (Plan, Do, Study, Act) cycles. The experience of patients, providers and frontline staff was captured through semi-structured interviews. • Data Analysis: Basic descriptive statistics were performed with STATA v13. Objective • To examine the feasibility and acceptability of using a validated screening tool for PTSD in a busy, urban collaborative care FQHC that predominantly serves adults experiencing homelessness in Oakland, California. Table 2. Qualitative Data: Stakeholder Perspectives on the Implementation of the Instrument Results • 50% of our patients completed the screening questionnaires at least once during the study period. • Acceptability was mixed given the qualitative feedback and concern that more patients are declining to complete the forms over time. • The PCL-C screening tool was chosen in addition to the PHQ-9 (required) to better reflect the high prevalence of multi- generational trauma in our patient population. • Of the 124 patients screened for PTSD, 69% (85 patients) screened positive (sore of 44 or higher out of 85). Acknowledgments & Contact Info • This work was supported by San Francisco Department of Public Health, Community Behavioral Health Services, Alameda County Health Care for the Homeless, and LifeLong Medical Care. We would like to acknowledge Smriti Joneja for help with data extraction. • [email protected] University of California, San Francisco and Zuckerberg San Francisco General Hospital Aislinn Bird, MD, MPH; Melanie Thomas, MD, MS; Jennie Xu, BS; Jeffrey Seal, MD; James Dilley, MD; Christina Mangurian, MD, MAS Do I have to do this every time?: Implementing a PTSD Screening Instrument in a Community Health Center that Serves People Experiencing Homelessness Background • Since 2015, the U.S. Health Resources & Services Administration (HRSA) has required that Federally Qualified Health Centers (FQHCs) screen for depression in all adult patients. • Some clinic populations also have a high prevalence of other behavioral health disorders such as Post Traumatic Stress Disorder. • There is little literature on screening tools other than the PHQ-9 for depression or about how frequently to administer the screening tools. • More evidence is needed to determine best practices for the implementation of screening tools beyond depression and for specific clinical populations. Study Setting • The TRUST Clinic is a collaborative care FQHC that primarily serves African-American low- income patients with a high prevalence of multi- generational trauma who are experiencing homelessness. • The clinic offers a wide range of services: behavioral health (medication management, psychotherapy, groups), primary care, health and wellness coaching, buprenorphine clinic, acupuncture, podiatry, along with a welcoming environment and free access to showers, bathrooms, clothing, a TV, tea, coffee and food. Discussion & Future Directions • Implementing the screening tools was feasible, as evidenced by 50% of the patient population completing the screening tools. • Clinics working with people experiencing homelessness should screen for trauma and PTSD. • More research is needed to determine the frequency of administering screening tools that is most acceptable and clinically relevant. • We plan to develop a provider specific patient registry (modeled after the AIMS Center) to track patient engagement, symptoms and other population-health measurements with the assistance of a Patient Care Coordinator. Clinic staff at the 7 th Anniversary of the ACA Celebration Positive Negative Patients “That feels good to see (graph of improving scores). I really have been feeling better!” “I felt a little uncomfortable filling it out in the waiting room. I felt like everyone was looking at me.” “Nothing has changed! I just did this yesterday.” Behavioral Health Providers “Maybe it will help identify those who are struggling who would downplay what is going on face to face, but more comfortable being honest on paper.” “The best indicator for how someone is doing is their functionality. Their relationships, human connections, being able to get out of bed in the morning. This is not captured in the screening tools.” Primary Care Providers “I think it saves me time and helps me prioritize what problems to address that day.” “It’s another thing to review which is hard when a patient’s problem list is so long.” Front Line Staff “I guess it’s a quick way to address psych stuff, which is important.” “I think most patients are indifferent, but are willing to do it if it helps their doctor.” “This sucks!” “Sometimes patients are annoyed when I ask because they had just filled it out earlier in the week.” Table 1. Overall TRUST Clinic Demographics since Opening December Average Age 45 (20-65) Sex Male 65% (301) Female 35% (160) Race African American 52% (241) White 17% (81) Mixed Race/Other 13% (61) Declined to Specify 17% (81) Housing Status Homeless 57% (263) Not Homeless 41% (191) Unknown 2% (7) Language English 98% (451) Other 2% (10) 40% (146) 23% (85) 10% (35) 11% (39) 0 10 20 30 40 50 60 PHQ-9 PCL-C % of Total Patients Screening Tool Positive Screens Negative Screens Staff members with the screening tools
Transcript of Do I have to do this every time?: Implementing a PTSD ... · stakeholder engagement and a workflow...
Demographics
Figure 1. Screening Tool Results
Methods• Study Type: Mixed-methods pilot study to
examine feasibility and acceptability of screening tool implementation.
• Participants: Patients, behavioral health and primary care providers, medical assistants, health and wellness coaches, a registered nurse and intensive case manager at TRUST from October 1, 2017 to March 31, 2017.
• Study Procedure: We worked with staff to create stakeholder engagement and a workflow for administration of the PCL-C (PTSD CheckList-Civilian Version) and PHQ-9 (Patient Health Questionnaire) to meet the requirement of screening at every visit.
• A receptionist gave the screening tools to patients at registration for their appointments. Patients completed the survey tools in the waiting room and gave results to clinic staff. Survey results were entered into the EMR.
• We assessed implementation of the screening tools through multiple PDSA (Plan, Do, Study, Act) cycles. The experience of patients, providers and frontline staff was captured through semi-structured interviews.
• Data Analysis: Basic descriptive statistics were performed with STATA v13.
Objective• To examine the feasibility and
acceptability of using a validated screening tool for PTSD in a busy, urban collaborative care FQHC that predominantly serves adults experiencing homelessness in Oakland, California.
Table 2. Qualitative Data: Stakeholder Perspectives on the Implementation of the Instrument
Results• 50% of our patients completed the
screening questionnaires at least once during the study period.
• Acceptability was mixed given the qualitative feedback and concern that more patients are declining to complete the forms over time.
• The PCL-C screening tool was chosen in addition to the PHQ-9 (required) to better reflect the high prevalence of multi-generational trauma in our patient population.
• Of the 124 patients screened for PTSD, 69% (85 patients) screened positive (sore of 44 or higher out of 85).
Acknowledgments & Contact Info• This work was supported by San Francisco Department of Public
Health, Community Behavioral Health Services, Alameda County Health Care for the Homeless, and LifeLong Medical Care. We would like to acknowledge Smriti Joneja for help with data extraction.
University of California, San Francisco and Zuckerberg San Francisco General Hospital
Aislinn Bird, MD, MPH; Melanie Thomas, MD, MS; Jennie Xu, BS; Jeffrey Seal, MD; James Dilley, MD; Christina Mangurian, MD, MAS
Do I have to do this every time?: Implementing a PTSD Screening Instrument in a Community Health Center that Serves People Experiencing Homelessness
Background• Since 2015, the U.S. Health
Resources & Services Administration (HRSA) has required that Federally Qualified Health Centers (FQHCs) screen for depression in all adult patients.
• Some clinic populations also have a high prevalence of other behavioral health disorders such as Post Traumatic Stress Disorder.
• There is little literature on screening tools other than the PHQ-9 for depression or about how frequently to administer the screening tools.
• More evidence is needed to determine best practices for the implementation of screening tools beyond depression and for specific clinical populations.
Study Setting• The TRUST Clinic is a collaborative care FQHC
that primarily serves African-American low-income patients with a high prevalence of multi-generational trauma who are experiencing homelessness.
• The clinic offers a wide range of services: behavioral health (medication management, psychotherapy, groups), primary care, health and wellness coaching, buprenorphine clinic, acupuncture, podiatry, along with a welcoming environment and free access to showers, bathrooms, clothing, a TV, tea, coffee and food.
Discussion & Future Directions• Implementing the screening tools was
feasible, as evidenced by 50% of the patient population completing the screening tools.
• Clinics working with people experiencing homelessness should screen for trauma and PTSD.
• More research is needed to determine the frequency of administering screening tools that is most acceptable and clinically relevant.
• We plan to develop a provider specific patient registry (modeled after the AIMS Center) to track patient engagement, symptoms and other population-health measurements with the assistance of a Patient Care Coordinator.
Clinic staff at the 7th Anniversary of the ACA Celebration
Positive Negative
Patients“That feels good to see (graph of improving scores). I really have been feeling better!”
“I felt a little uncomfortable filling it out in the waiting room. I felt like everyone was looking at me.”
“Nothing has changed! I just did this yesterday.”
Behavioral Health Providers
“Maybe it will help identify those who are struggling who would downplay what is going on face to face, but more comfortable being honest on paper.”
“The best indicator for how someone is doing is their functionality. Their relationships, human connections, being able to get out of bed in the morning. This is not captured in the screening tools.”
Primary Care Providers
“I think it saves me time and helps me prioritize what problems to address that day.”
“It’s another thing to review which is hard when a patient’s problem list is so long.”
Front Line Staff
“I guess it’s a quick way to address psych stuff, which is important.”
“I think most patients are indifferent, but are willing to do it if it helps their doctor.”
“This sucks!”
“Sometimes patients are annoyed when I ask because they had just filled it out earlier in the week.”
Table 1. Overall TRUST Clinic Demographics since Opening December
Average Age 45 (20-65) SexMale 65% (301) Female 35% (160) RaceAfrican American 52% (241) White 17% (81) Mixed Race/Other 13% (61) Declined to Specify 17% (81) Housing Status Homeless 57% (263) Not Homeless 41% (191) Unknown 2% (7) Language English 98% (451) Other 2% (10)
40% (146)
23% (85)
10% (35)
11% (39)
0
10
20
30
40
50
60
PHQ-9 PCL-C
% o
f Tot
al P
atie
nts
Screening ToolPositive Screens Negative Screens
Staff members with the screening tools
